There was no difference in the rate of positive angiography or major adverse cardiac events between the three strategies at 1 year.

Although the U.K.'s National Institute for Health and Clinical Excellence (NICE) guidelines recommend invasive imaging for higher-risk patients, Greenwood concluded that perhaps they "still drive more angiography than you need."

And those guidelines can be very complicated to begin with, according to session discussant Udo Sechtem, MD, of Robert-Bosch Medical Center in Germany. "The question is whether we can go easier than the NICE protocol."

Angiography was deemed unnecessary if a patient's fractional flow reserve was above 0.8 or if quantitative coronary angiography in coronary vessels at least 2.5 mm wide showed no diameter stenosis over 70% in one view (or 50% in two orthogonal views).

That 3-year adverse events never climbed above 4% in all groups showed that Greenwood was working with low-risk populations, Sechtem commented. "This is such a low risk cohort that symptomatic treatment combined with preventive medication, then followed by revascularization, should be the first step."

The investigation could have tested coronary CT angiography as well, Sechtem suggested.

PET emerged as the winner in a head-to-head comparison with coronary CT angiography and single-photon emission computed tomography (SPECT) for catching myocardial ischemia, according to results of a study dubbed PACIFIC.

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